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Review
Post cardiac arrest syndrome
Síndrome posparo cardiaco
José Ricardo Navarro-Vargasa,
Corresponding author
jrnavarrovargas@hotmail.com

Corresponding author at: Universidad Nacional de Colombia, Calle 42 22 29, Bogotá, DC 0571, Colombia. Tel.: +57 3406593.
, José Luis Díazb
a Associate Professor, School of Medicine, Universidad Nacional de Colombia, Colombia
b Assistant Professor, Department of Anesthesia and Critical Care, Mayo Clinic, FL, USA
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1972 the Russian pathophysiologist Vladimir Negovsky described the syndrome as &#8220;a post-resuscitation disease&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; since it involves a series of uncontrolled events&#44; the International Liaison Committee on Resuscitation &#40;ILCOR&#41; adopted the term post cardiac arrest syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence rate due to all cardiac causes is 460&#44;000 deaths&#47;year&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Prospective trials refer to 350&#44;000 coronary disease-related deaths&#47;year&#59; this is 1&#8211;2&#47;1000 people for the American population&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There are survival reports of patients with extra-hospital cardiac arrest of 23&#46;8&#37; at the time of admission and of 7&#46;6&#37; at the time of discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Biological death depends on the cardiac arrest mechanism&#44; on the underlying disease and on the delay in starting the resuscitation maneuvers &#40;CPR&#41;&#46; A poor neurological prognosis after 4&#8211;6<span class="elsevierStyleHsp" style=""></span>min of an unattended arrest is irreversible&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and hence resuscitation must be a constant mission&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">When the arrest mechanism is an asystole or a pulseless electrical activity &#40;PEA&#41;&#44; the progression to neurological injury is faster and leads to a worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Mild therapeutic hypothermia &#40;32&#8211;34<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; is the gold standard in post-arrest care&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A narrative review of the literature using Medline via PubMed and Clinical Trials using the terms MeSH cardiac arrest &#8211; Cardiopulmonary Resuscitation and no term MeSH Post cardiac arrest syndrome was carried out&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Clinical evolution</span><p id="par0035" class="elsevierStylePara elsevierViewall">Once the patient recovers spontaneous cardiac circulation&#44; a cascade of events develops&#44; mainly characterized by anoxic brain injury&#44; post cardiac arrest myocardial dysfunction&#44; &#8220;ischemic&#47;reperfusion&#8221; systemic response&#44; and the typical pathology of the triggering cause of the cardiac arrest&#46; The clinical evolution shall be dependent on clinical conditions such as the patient&#39;s co-morbidities&#44; the duration of the ischemic lesion and the cause that triggered the cardiac arrest&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Pathophysiology</span><p id="par0040" class="elsevierStylePara elsevierViewall">Oxygen deficiency and generalized acidosis develop during cardiac arrest&#46; If the victim is resuscitated using CPR&#47;defibrillation maneuvers&#44; with resumption of spontaneous circulation&#44; PCSS develops&#44; which is characterized by a systemic inflammatory response of the immune system and of coagulation&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Cell damage seems to affect the enzyme calpain and peroxidation caused by oxygen free radicals that begin to develop during the phase of global ischemia and perpetuates during reperfusion&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The main cause of extra-hospital cardiac arrest in the adult is acute myocardial infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> There are many other pathologies leading to multisystem failure and subsequent cardiac arrest in the hospitalized patient&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Treatment</span><p id="par0050" class="elsevierStylePara elsevierViewall">According to the ILCOR<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;10</span></a> document&#44; the PCAS classification follows physiological criteria in five phases&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Immediate care&#58; the initial 20<span class="elsevierStyleHsp" style=""></span>min following the patient&#39;s spontaneous recovery of circulation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Early phase&#58; from 20<span class="elsevierStyleHsp" style=""></span>min to 6&#8211;12<span class="elsevierStyleHsp" style=""></span>h&#44; when critical protective and therapeutic measures are required for a successful outcome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Intermediate phase&#58; from 6&#8211;12<span class="elsevierStyleHsp" style=""></span>h to 72<span class="elsevierStyleHsp" style=""></span>h a close surveillance and ICU treatment are required consistent with the therapeutic objectives&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Recovery phase&#58; comprises the patient&#39;s condition after the initial 72<span class="elsevierStyleHsp" style=""></span>h when there is a clearer diagnosis and a more predictable result&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Rehabilitation phase&#58; focuses on the patient&#39;s complete recovery&#46; Any electrolytic abnormalities shall be corrected during phases 1 and 2&#44; in addition to providing inotropic support and optimized oxygenation&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></li></ul></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Goal-targeted therapy</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ventilation support</span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Normocapnia &#40;PaCO<span class="elsevierStyleInf">2</span> between 40 and 45<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; However&#44; arterial gasometry should be properly interpreted in patients undergoing therapeutic hypothermia&#46; When a patient reaches a central body temperature of close to 33<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; the actual PaCO<span class="elsevierStyleInf">2</span> may be up to 7<span class="elsevierStyleHsp" style=""></span>mmHg below the value in the arterial gases machine&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Hyperventilation has been associated with a drop in coronary perfusion and venous return&#44; in addition to cerebral vasoconstriction&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Normoxia&#46; Both&#44; hypoxia and hyperoxia &#40;PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>300<span class="elsevierStyleHsp" style=""></span>mmHg&#41; may result in secondary neurological injury&#46; Using an inspired oxygen fraction to maintain the arterial saturation between 95&#37; and 99&#37; or a PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHg is considered very reasonable&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However&#44; other authors have not achieved similar results&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Hemodynamic support</span><p id="par0095" class="elsevierStylePara elsevierViewall">Systemic perfusion and in particular cerebral perfusion have prognostic implications&#46; Cardiac arrest patients experience a loss of cerebral self-regulation&#46; Based on positron emission tomography studies&#44; the suggestion is to maintain a mean pressure between 80 and 100<span class="elsevierStyleHsp" style=""></span>mmHg because this is the range in which perfusion matches the cerebral metabolic activity&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> During the first 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h following the cardiac arrest&#44; vasopressors and inotropic agents are usually needed&#46; Transthoracic echocardiography may assist in accomplishing this goal&#46; Apparently there is no difference in terms of the clinical prognosis regardless of the vasopressor &#40;norepinephrine versus dopamine&#41;&#46; Monitoring the mixed venous saturation may help in the interpretation of pharmacological interventions such as the introduction of inotropic agents&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Hypothermia has shown huge benefits since 2002&#59;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> however&#44; the procedure is not standardized in every country&#46; There is an Italian study in ICUs indicating that only 16&#37; used the therapeutic hypothermia protocol&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Hypothermia Management Scheme<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></span><p id="par0105" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">The induction phase &#40;body temperature between 32<span class="elsevierStyleHsp" style=""></span>&#176;C and 34<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#46; It should be started early to prevent neuro-excitotoxicity&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> It has been shown that the benefit of hypothermia will not be achieved if it is introduced after 6<span class="elsevierStyleHsp" style=""></span>h of the spontaneous return of circulation&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Both PRINCE &#40;Pre-ROSC Intranasal Cooling Effectiveness&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and Nagao<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> trials showed that initiating hypothermia before the patient recovers spontaneous cardiac circulation during CPR improves the neurological results and protects the myocardium from reperfusion injuries&#46; Therapeutic hypothermia may not last less than 6<span class="elsevierStyleHsp" style=""></span>h and it should be continued for 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Some recommend starting a rapid saline solution infusion at 4<span class="elsevierStyleHsp" style=""></span>&#176;C to accomplish these goals&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The rate at which the body temperature drops is close to 1<span class="elsevierStyleHsp" style=""></span>&#176;C in 15<span class="elsevierStyleHsp" style=""></span>min&#44; when administering 1 liter of cold saline solution&#46; This method is thought to be comparable to or even better than the use of intravascular catheters&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> The infusion of 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg of saline solution at 4<span class="elsevierStyleHsp" style=""></span>&#176;C lowers the body temperature at a rate of over 2<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;h&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;32</span></a> Chills are one of the side effects of cooling down because of the rise in metabolic oxygen consumption&#59; the recommendation to prevent chills includes administering magnesium sulfate &#40;5<span class="elsevierStyleHsp" style=""></span>g&#47;5<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; sedation and proper analgesia&#44; in addition to the occasional administration of muscle relaxants&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;24</span></a> A very common intravenous sedation regime is titrating with a continuous infusion of Propofol &#40;up to 50<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#41; and Fentanyl&#46; Hypothermia between 32<span class="elsevierStyleHsp" style=""></span>&#176;C and 34<span class="elsevierStyleHsp" style=""></span>&#176;C results in a drop in cardiac output &#40;between 25&#37; and 40&#37;&#41; at the expense of a heart rate decrease&#46; Arrhythmias occur at much lower temperatures than these ranges or as a result of electrolyte imbalances&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The most destabilizing factors during this phase are hypovolemia and electrolyte imbalances &#40;hypokalemia and hypomagnesemia&#41;&#46; Increased diuresis results in a hydro-electrolytic imbalance&#44; hemoconcentration and a rise in blood viscosity&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">The maintenance phase should be free of any temperature variations beyond 0&#46;2&#8211;0&#46;5 degrees centigrade of the temperature achieved&#46; Be very careful with the metabolic requirements of the patient since these are reduced in up to 50&#37; and monitor coagulation&#44; although different trials do not show a significant risk of bleeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;34</span></a> Hypothermia extends the half-life of all drugs&#46; The administration of muscle relaxants may suppress chills and hence prevent rises in body temperature&#46; However&#44; muscle relaxants may mask seizures &#40;that are present in up to 44&#37; of the cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> The therapeutic approach includes the use of multiple anti-convulsive agents as is the case in status epilepticus &#40;valproic acid&#44; phenytoin&#44; midazolam&#44; phenobarbital and propofol&#41; because seizures tend to be refractory&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The premise during the warm-up phase is to slowly recover the temperature at a rate of 0&#46;2&#8211;0&#46;3 degrees centigrade&#46; It is recommended to start warming-up after 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h of introducing the hypothermia until the temperature is normalized&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;24</span></a> It is usual to experience hyperkalemia&#44; cerebral edema&#44; and seizures during this phase&#59; likewise&#44; ruling out any risk of infection is a priority since one of the effects of hypothermia is the inhibition of the immune response&#46; The use of antibiotic prophylaxis is only indicated for high-risk patients or in prolonged hypothermia &#40;over 48<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The level of coagulopathy is considered to be mild when compared against that of cardiac arrest victims who are maintained at a normal temperature&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Increased infection rates have been described associated with therapeutic hypothermia for 24<span class="elsevierStyleHsp" style=""></span>h&#59; however&#44; it has not been associated with higher mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;39</span></a> There can also be bradycardia&#44; prolongation of the QTc segment&#44; hyperglycemia&#44; diuresis with subsequent hypokalemia&#44; hypomagnesemia and hypofosfatemia&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Hypothermia protection</span><p id="par0130" class="elsevierStylePara elsevierViewall">During the first phase&#44; when the patient recovers spontaneous circulation&#44; hypothermia reduces the metabolic consumption of oxygen and glucose&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">During the second phase&#44; hypothermia reduces the occurrence of excitatory amino acids&#44; particularly glutamate&#59; these amino acids are responsible for the activation of the cytotoxic cascade&#44; the formation of reactive oxygen species &#40;ROS&#41; and nitric oxide&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">During the third phase&#44; hypothermia preserves the integrity of cell membranes interfering with the action of calpain and thus preventing the occurrence of cerebral edema&#44; neuronal death and blood brain barrier injury&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;43</span></a><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><p id="par0145" class="elsevierStylePara elsevierViewall">The benefits of therapeutic hypothermia have been very well explained in a recent meta-analysis&#46; Patients treated with therapeutic hypothermia exhibited improved neurological function &#40;RR 1&#46;55&#59; 95 CI 1&#46;22&#8211;1&#46;96&#41; and had a higher probability of survival at discharge &#40;RR 1&#46;35&#59; 95 CI 1&#46;10&#8211;1&#46;65&#41; compared to patients not treated with hypothermia&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><p id="par0150" class="elsevierStylePara elsevierViewall">The international agencies &#40;AHA &#8211; ERC&#41; have accepted and promoted the indication of hypothermia for managing the post cardiac arrest syndrome&#44; not only in defibrillator-amenable patients&#44; but also in cases of worse AESP prognosis and asystole in which the most important prognostic factor is the <span class="elsevierStyleItalic">initiation of therapy</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;29</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Indications for therapeutic hypothermia</span><a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;45</span></a><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0070"><p id="par0160" class="elsevierStylePara elsevierViewall">Return to spontaneous cardiac circulation following cardiac arrest &#40;any type of rhythm&#41;</p></li><li class="elsevierStyleListItem" id="lsti0075"><p id="par0165" class="elsevierStylePara elsevierViewall">Coma</p></li><li class="elsevierStyleListItem" id="lsti0080"><p id="par0170" class="elsevierStylePara elsevierViewall">Over 18 years old</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0085"><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Absolute contraindications</span><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0090"><p id="par0180" class="elsevierStylePara elsevierViewall">Non-compressible active bleeding</p></li><li class="elsevierStyleListItem" id="lsti0095"><p id="par0185" class="elsevierStylePara elsevierViewall">Do not resuscitate medical order &#40;DNR&#41;</p></li></ul></p></li></ul></p><p id="par0190" class="elsevierStylePara elsevierViewall">The hypothermia protocol must be interrupted in the presence of sepsis or pneumonia&#44; refractory hemodynamic instability and severe refractory arrhythmia&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Hypothermia in patients with a FV cardiac arrest has an NNT of 6 &#40;confidence interval of 4&#8211;13&#41;&#46; Despite the consistency of the trials in terms of the rhythm of presentation of the arrest&#44; cooling method used&#44; time to reach therapeutic hypothermia and duration thereof&#44; no follow-up studies have been made beyond one year to establish the final neurological involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Hypothermia should not be delayed&#44; even when the patient requires transluminal percutaneous coronary angioplasty&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The best site to monitor the central temperature is through the pulmonary artery catheter or the central venous line&#59; however&#44; other sites are recommended such as the esophagus and the bladder&#44; because they are easy to place and have minimal effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;48</span></a> The bladder temperature may be misinterpreted in the presence of oliguria&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">When should you do percutaneous coronary intervention &#40;PCI&#41; and thrombolysis</span><p id="par0210" class="elsevierStylePara elsevierViewall">Ask about any history of coronary heart disease&#44; prior chest pain symptoms and initial arrest rhythm &#40;if the QRS tracing in the ECG is widened&#44; it is most likely of coronary etiology&#41;&#59; however&#44; the literature has not found a positive predictive value for coronary obstruction of these two parameters&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Thrombolysis is only recommended in isolated cases of pulmonary embolism and acute myocardial infarction with ST elevation &#40;IAMST&#41; and a 3-h therapeutic window or in the case of IAMST&#44; with no other option for invasive coronary intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">In cardiac arrest patients with no evident extra cardiac cause or who present ST elevation in the ECG or sudden left branch blockade&#44; an early angiographic exploration is recommended&#44; followed by percutaneous coronary intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> In a report written by Spaulding et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> 49&#37; of all cardiac arrest survivors who underwent routine coronary angiography showed a severe coronary obstruction&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Further randomized clinical trials are needed showing the positive impact of emergency percutaneous coronary intervention in this syndrome&#46; As of now&#44; the studies reporting benefits with the use of PCI-associated therapeutic hypothermia exhibit various biases and undetermined confounding factors&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The similarity of the cardiohemic involvement of PCAS<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> to septic shock has led to the search of alternative aggressive management options with quite successful results such as circulatory support with extracorporeal oxygenation<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> and renal replacement therapy with high volume hemofiltration&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">In refractory cardiac arrest patients&#44; the alternative to use venous-arterial extracorporeal membrane oxygenation and PCI has been suggested&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Recommendation for neurological follow-up of the patient</span><p id="par0240" class="elsevierStylePara elsevierViewall">The brain is the key organ in resuscitation&#44; hence the high importance given to therapeutic hypothermia&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> There is an interesting article on the &#8220;self-fulfilling prophecy&#8221;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> that states that no negative prior judgments should be made in a patient who has overcome the arrest&#44; regardless of the cause because by not doing what should be done&#44; the patient will not survive&#44; giving the false impression that what is appropriate is not to start any medical intervention under these circumstances&#46; However&#44; there is always room for uncertainty in every prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">The prognosis after the clinical and paraclinical exams at different points in the evolution must have a 72-h &#40;3 days&#41; period of observation before any decision is made&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> The American Academy of Neurology suggests that in the absence of brain death&#44; findings of the clinical examination such as absence of corneal or pupillary reflexes&#44; of motor response or extended absence of motor response&#44; lead to a high rate or poor prognosis and consequently low false positives&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Efforts have been made to identify serum markers for predicting the development of multiple organ failure in PCAS patients&#46; Soluble Ang1 factor stabilizes the endothelium Ang2 levels&#44; and a higher proportion of Ang2&#47;Ang1 is predictive of multiple organ failure and poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">High procalcitonin levels are shown to be associated with PCAS and adverse neurological prognosis rather than to early infection in patients with anoxic encephalopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Among the clinical factors themselves&#44; a research comparing two hospitals in distant geographical regions showed that the pre- and intra-cardiac arrest conditions determine the severity of the PCAS&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Prognostic factors<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></span><p id="par0315" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0265" class="elsevierStylePara elsevierViewall">Patient history&#58; old age &#8211; diabetes &#8211; sepsis &#8211; CVA</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Cardiac arrest and resuscitation conditions&#58; time elapsed since the cardiac arrest and the start of CPR &#8211; CPR quality &#8211; asystole as arrest rhythm &#8211; implementation of a protocol for managing the PCAS&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">Later evolution in accordance with the neurological examination&#44; neurophysiological exams&#44; neuroimaging&#44; biochemical markers and intracranial Doppler&#46;</p></li></ul></p><p id="par0280" class="elsevierStylePara elsevierViewall">The two scales used to establish the degree of disability and the quality of life are the Glasgow prognostic scale<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and the Glasgow-Pittsburgh<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> scale for categorizing brain performance&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">What is currently being done&#63;</span><p id="par0285" class="elsevierStylePara elsevierViewall">A large international prospective trial was completed coordinated from Sweden<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> &#8211; the TTM trial &#40;Target Temperature Management&#44; identified as <a id="intr0005" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT01020916">NCT01020916</a>&#41;&#44; whose results were published late in 2013&#46; The purpose of the trial was to establish the level of evidence of hypothermia for the management of PCAS with optimal control to avoid hyperthermia in both groups&#59; <span class="elsevierStyleItalic">n</span>&#58; 939 adult patients&#46; Comparison&#58; controlled hypothermia &#40;33<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; versus patients maintained with a temperature of 36<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Period of time during which the patients were evaluated&#58; up to 180 days&#46; The results obtained are controversial with regard to the optimal threshold of hypothermia&#46; The conclusion of the trial was based on a strict temperature control &#40;below 36<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; to prevent hyperthermia&#44; which is considered a determining factor for poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> Emphasis was also placed on the establishment of standardized protocols&#44; even for each subgroup of patients who may benefit from individualized treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">The recommendation is to optimize the perfusion of vital organs in addition to the brain&#44; since the prevalence of multiple extra-cerebral organ failure impacts mortality&#44; particularly the involvement of the cardiovascular &#40;depends on the fine vasopressor support&#41; and respiratory system &#40;by providing improved oxygenation&#41;&#46; An independent association has been identified between these two organs and their involvement has been linked to a higher hospital mortality in PCAS&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusion</span><p id="par0295" class="elsevierStylePara elsevierViewall">PCAS is an entity that has been recognized for the last 40 years&#59; however&#44; the treatment for PCAS has only been established in an organized manner in the last decade&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">The pathophysiology includes a serious involvement of the brain and leads to myocardial dysfunction and systemic inflammation&#46; Failure to intervene early on results in irreversible brain injury&#44; vegetative state and death&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0305" class="elsevierStylePara elsevierViewall">Authors&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicts of interest</span><p id="par0310" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Hypothermia Management Scheme"
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            2 => array:2 [
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              "titulo" => "Hypothermia protection"
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        8 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "When should you do percutaneous coronary intervention &#40;PCI&#41; and thrombolysis"
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          "identificador" => "sec0055"
          "titulo" => "Recommendation for neurological follow-up of the patient"
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              "identificador" => "sec0080"
              "titulo" => "Prognostic factors"
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          "identificador" => "sec0060"
          "titulo" => "What is currently being done&#63;"
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          "titulo" => "Funding"
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          "identificador" => "sec0075"
          "titulo" => "Conflicts of interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2013-07-29"
    "fechaAceptado" => "2014-01-20"
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          "titulo" => "Keywords"
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            0 => "Heart arrest"
            1 => "Cardiopulmonary resuscitation"
            2 => "Percutaneous coronary intervention"
            3 => "Hypothermia induced"
            4 => "Blood Circulation"
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      ]
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          "titulo" => "Palabras clave"
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            0 => "Paro cardiaco"
            1 => "Resucitaci&#243;n cardiopulmonar"
            2 => "Intervenci&#243;n coronaria percut&#225;nea"
            3 => "Hipotermia inducida"
            4 => "Circulaci&#243;n sangu&#237;nea"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Resuscitation from cardiac arrest with global ischemia restores spontaneous circulation in some patients&#59; however&#44; survival depends on many factors associated with post cardiac arrest syndrome&#46; During the last ten years&#44; the understanding and control of these factors have improved the prognosis in a subgroup of patients&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the pathophysiology and current management of the post cardiac arrest syndrome &#40;PCAS&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methodology</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Narrative review of the literature using Medline via PubMed and Clinical Trials&#44; using the terms MeSH cardiac arrest &#8211; Cardiopulmonary Resuscitation and &#40;no term MeSH&#41; Post cardiac arrest syndrome&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical trials have established a set of management protocols and guidelines based on therapeutic objectives with survival rates exceeding 50&#37; of the cardiac arrest victims&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The management of this syndrome has actually strengthened the last link in the survival chain by standardizing the evaluation and selection of cardiac arrest victims via a therapeutic hypothermia protocol and early percutaneous coronary intervention&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La reanimaci&#243;n en el paro cardiaco con isquemia global logra restablecer la circulaci&#243;n espont&#225;nea en algunos pacientes&#59; sin embargo&#44; la sobrevida depende de muchos factores que explican el s&#237;ndrome posparo cardiaco&#46; El entendimiento y el control de estos factores durante la &#250;ltima d&#233;cada han logrado mejorar el pron&#243;stico en un subgrupo de pacientes&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir la fisiopatolog&#237;a y el manejo actual del s&#237;ndrome posparo cardiaco&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Metodolog&#237;a</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n narrativa de la literatura a trav&#233;s de las bases electr&#243;nicas de Medline v&#237;a PubMed y Ensayos Cl&#237;nicos usando los t&#233;rminos MeSH <span class="elsevierStyleItalic">Cardiac arrest &#8211; Cardiopulmonary Resuscitation</span> y &#40;el t&#233;rmino no MeSH&#41; <span class="elsevierStyleItalic">Post cardiac arrest syndrome&#46;</span></p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los estudios cl&#237;nicos han establecido una serie de protocolos y gu&#237;as de manejo basadas en objetivos terap&#233;uticos con tasas de sobrevida que superan el 50&#37; de las v&#237;ctimas de paro cardiaco&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Actualmente el manejo de este s&#237;ndrome ha fortalecido el &#250;ltimo eslab&#243;n dela cadena de supervivencia al estandarizar la evaluaci&#243;n y la selecci&#243;n de v&#237;ctimas de paro cardiaco con un protocolo de hipotermia terap&#233;utica e intervenci&#243;n coronaria percut&#225;nea precoz&#46;</p>"
      ]
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Navarro-Vargas JR&#44; D&#237;az JL&#46; S&#237;ndrome posparo cardiaco&#46; Rev Colomb Anestesiol&#46; 2014&#59;42&#58;107&#8211;113&#46;</p>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos